HCGC Regional Learning Session:

Data Driven Population Health

October 9th, 2019

Welcome!

Supporters

100% of our Board of Directors & Staff Individual & Corporate Donations

One of over 30 Regional Health Improvement Collaboratives (RHICs) across the country

HCGC is a non-profit organization with multi-stakeholder governance, fully supported by grants, sponsorships and project work

Our Work Toward Better Value

Regional Learning Session Year in

Review

In April 2019 we…• Explored National Efforts for Population Health

• IHI Triple Aim for Population Health

• Shared free tools and resources for organizations to utilize to assess and improve their population health efforts

• Pathways to Population Health

• Learned about local/regional initiatives including research and outcomes regarding population health, including the HUB

Background

P2PH is the product of collaboration among five organizations leveraging our shared assets and

unique strengths to help health care organizations accelerate population health improvement efforts.

Source: Pathways to Population Health, 2018

Four Portfolios of Population Health

In August, we……• Took a deeper dive into PCORI Resources for

research-including results written for patients, and research references we can all use as another fantastic community asset in our work toward better population and community health

• Hosted an interactive session and began to create a common community vision toward population health to work toward and build our Central Ohio Communities of Solutions

• Engaged with CPC+ Practices

Today we will…• Look at data, which was the one common

element to the April and August discussions:

• Sharing it

• Using it

• Too much, not enough, not easily digestible

• Not available broadly to the entire community

• Small groups to have a conversation about data-driven population health

Today we will…• Share what data is available in our region,

including evolutions with CliniSync

• Release our newest Quality Transparency Data, with added HUB data

• Ask a community panel of experts how they use data to support individual patients and population health

• Take questions and feedback

How do you share data now for better patient/client outcomes, for quality and process improvement?

From your unique perspective, what data elements are critical to be sharing but aren’t being shared?

What data elements would be ideal for community knowledge/benchmarking and health status?

HCGC Data: Quality Transparency and HUB

Quality Transparency and Improvement

Collect, aggregate, and report 9 NQF-endorsed quality measures from over 160 practice sites serving over 800,000 lives in Columbus and surrounding counties

Host work sessions for practices to assess data, set goals, and align improvement activities at a community level

QT Project Review

30%

48% 45%

53%49%

57% 59% 59%

0%

20%

40%

60%

80%

100%

1/1/2014 -12/31/2014

7/1/2014 -6/30/2015

1/1/2015 -12/31/2015

7/1/2015 -6/30/2016

1/1/2016 -12/31/2016

7/1/2016 -6/30/2017

1/1/2017 -12/31/2017

07/01/2017 -06/30/2018

Percent of patients who had appropriate screening for colorectal cancer

Actual Target

Current Data Use: Clinical

• Collect site-level quality data (clinical) from primary care and behavioral health providers on nine quality measures to guide improvement efforts

• Publish a regional quality report twice per year

• Provides benchmarking and trends, data gap insights

• Expanding the number of practices, specialties, and quality measures

• Limitations: data points, frequency, timeliness

Current Data Use: HUB/SDOH

• Collect patient level data on both risks and outcomes that have addressed risks in real time

• 10 community agencies contributing

• Have not established a public reporting cadence yet

• Could add insight to service delivery, trends, gaps

• Expanding rapidly-clients, services, agencies

Visioning• Functioning integrated data system with multilevel

reporting shared with providers and community partners to inform connections, performance and improvement work

• Culture evolution in Central Ohio in transparency and improvement

• Not just clinical and cost but social/public health and SDOH and at the community/regional level

Our first attempt!

• Focus on HUB adult (18+, non-pregnant, non-mothers) clients to align with QT

• Highlighted hypertension data to align with QT

• Not apples to apples-HUB is patient level data, self reported; QT report is currently self reported at the practice level

• We recognize this isn’t actionable yet-building blocks of information

Zip codes with

Practice Sharing

Data in QT Report

Zip codes with 4+ Adult HUB Clients

QT Reporting Practice & HUB Adult Client Zip Code Comparison

Zip codes with

Practice Sharing

Data in QT Report

QT Reporting Practice & HUB Adult Clients w/ Medical Home Pathway Zip Code Comparison

Zip codes with 4+

Adult HUB Clients w/ Med Home Pathway

HUB Chronic Conditions

Central Ohio Pathways HUB

Additional Data Reporting Opportunities

• Depression/PHQ-9

• Breast health

• Pregnancy/infant mortality

• Diabetes A1C

• Tobacco cessation

Questions/Feedback?

CliniSync

Community Reaction Panel

Mount Carmel Medical Group

The Ohio State University Wexner

Medical Center

OhioHealthHeart of Ohio Family Health Centers

Maria Courser, MD, FAAP

Joshua J. Joseph,M.D., FAHA

Buhari Mohammed,MD, MBA, CHCEF

Greg Sawchyn,MD, MBA

Community Reaction Panel: Strategic Questions

• Share with us your organization’s journey in obtaining and using data for positive patient outcomes and clinical quality improvement.

• In the past five years, social determinants of health have become a major focus in delivering care. How has this changed the way your organization operates and have you seen significant outcomes?

Questions/Feedback?

PCORI Research

PCORI Research

Finding PCORI Research on their website:

• https://www.pcori.org/

Next Steps and Closing Out

• Thank you for your fantastic contributions today

• Remember to fill out your harvest sheets!

• 2020 programming will be announced in December-please sign-up/follow/like us on our website and social media